- Email: [email protected]
The treatment of incomplete abortion
THE TREATMENT
OF INCOMPLETE
RESULTS WALT=
H. DUNE, (Fawn
the
IN 1,971
CASES
M.D., BROOKLYN,
Eings
County
T
ABORTION N. Y.
Eospital)
HIS study is an effort to evaluate the results in the different forms of treatment of incomplete abortion as reflected in the records of a large general hospital. To this end all cases admitted to the Gynecological Division of the Kings County Hospital for the five yea,rs, 1930 through 1934, were reviewed, including all readmissions. There were 1,971 cases. No case in which the period of gestation exceeded four months is included because these patients were admitted to the obstetric service and treated as premature labor, the technic of which differs considerably from the accepted routiue on the gynecologic service. The diagnosis in all cases was made by the history, findings 011 pelvic examinatiou and by the gross demonstration of placent,al tissue ; in the great majority of cases this was confirmed 1):~ a detailed pa.thologic report. Treatment, where the procedure is possible, is essentially as follows : After a careful history, with emphasis on any invasion of the uterus, the patient is shaved, scrubbed, the vulva painted with tr. iodine, a,nd Using sterile gloves, a gentle bimandraped as for a major operation. ual examination is made to determine the size and position of the uterus, the dilatation of the cervix and presence or absence of adnexal pathology. If no adnexal pathology is present, tha cervix is steadied with a tenaculum and the secundines removed with a smooth ovum forceps. The patient is then put to bed in Fowler’s position, an ampule of pituitrin is given, followed by a course of ergot, usually one drachm every four hours for six doses. After demonstrations of this technic by the resident, the work is done almost entirely by the internes, who change services every two months. An elevation of temperature is not considered a contraindication, in the absence of a history of repeated outside interference or of associated pelvic pathology. Gentleness in making the pelvic examination and in using the ovum forceps is st,ressed. Packs are rawly used, an occasional indication being where bleeding is moderate and the cervix not dilated enough to admit, the ovum forceps. A eurette is never used as it is felt that, while a simple intrauterine debridement to remove infectious material and promote drainage is practically 10%
1030
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
without danger, even in inexperienced hands, the trauma and massage osf the uterine walls incident to the use omfa curette are responsible for the poor results and consequent widespread condemnation of active interference expressed by authorities in t,his country. Patients treated conservatively include those where the cervix does not admit an ovum forceps, where other gross pelvic pathology is present or where it is known that the uterus has previously been invaded. A history of interference is, of course, usually denied; nevertheless, all patients are questioned closely. Conservative treatment includes the use of oxytocics, clyses, infusions, and occasionally transfusions. The intravenous drip has been of benefit in septic cases. Curettage was necessary in most of the conservatively treated patients, either before leaving the hospital or at a later admission. SUMMARY
3
*
OF 1971
CASES
Awraqc
hospital
.5
‘
9
Recorded Complications Deaths LO - 1.0 X Generabred Pentomtls..13 Corrected - 0.65% Pelvic Abscess -- ..-- .-. 8 Pelvis Cellullt~s----~-------~.0 Para 1 plus-80.5 % Pelvic Thrombophlobttls--3 Pdra 0 -/&5 % PerforԦkd Uterus~------~--~ 1 Avwaqe parity-Z.6 Opened as Ectoplc-~---.----- 2 Opened a5 Fabroad----.------1 Prwous Abortions Shock ------.-.. --- --- ---.-47 One plus -40.8% Anemia----------------------53 NOW _ 59./X Readmmsions ~-----~--.- ----32 Subsequent Interftrence---53 Awraqo - 0.78 (Uterus emptlcd on adm.l Averaqo Gestation2.6 Mos. No previous Chart
days
5.8
10
Averaqc Aqo-28.6 fExtrum.s 14 -50) Aqe Groups: 11 to20 - m9z 2.1 ,, 30 -50.6% 31 ” 40 -31.3% 41 * 50 - 6.5% Married-22.3X,Smqle.~6% WLte-&?l%,Neqro-/S6% Treated operatively: 1652 or 83.8% preqnancios-13.2%
1.
In Chart 1, a summary of the entire series, it will be seen that the figures agree closely with those reported recently in other series. The temperature average presented here and in subsequent tables is based on rectal temperatures, so 99” was taken as a base line. The 53 patients requiring subsequent interference were those who, after removal of secundines by means of the ovum forceps on admission, were curetted before discharge for persistent bleeding. In addition to these data may be added: Of 891 cases where the Wassermann was recorded, 43, or 4.8 per cent, were positive. Of 279 who admitted induction, 210 were self-induced, 35 were induced by midwives, 22 by physicians, and 12 “had abortions performed. ” The majority of the rest offered falls, exertion, worry, fright, and a host Of t,he deaths, 17 out of 20 of other explanations for the abortion. had the exact cause determined by autopsy.
DRANE :
TREATMENT
OF INCOMPLETE
ABORTIOK
1031.
In Chart 2 are listed all patients who were admitted with a normal temperature, with a comparison in average temperature range, hospital days, mortality, and complications between those of the group where the uterus was emptied on admission by means of the ovum forceps and those treated conservatively. It will be noted that of the patients treated conservatively, 132 required operative intervention before discharge, which was done on an average of 4.9 days after admission. Of the radically treated group, 19 required a second operative intervention, averaging 5.3 days after admission. The value of “P” requires explanation. In the comparison of faetors in unequal groups of a limited quantity an obvious source of error is that the observed difference may be due to chance rather than to an actual difference. Through the courtesy of Dr. A. T. Rasmussen. of the lrniversity of Minnesota. a formula used by Dunn for the deterA- Averaqe B- Averaqo
days 4.7 L-1 days 7 4 (----..J
Group A: Utrrus e-mp&d on admisswn Group 8: Trrated Conscrvatwely Casea A: 886
Cases 0: 297
Mortahty: Corr
1 - - 0.N % - - 0.11 %
Mortality: L-- 0.672 Correctrd:Z--0.675:
P: 13.4
Chart
2.
mination of statistical significance of comparisons in limited samples was modified to apply to the problem at hand. The modification was in expressing the answer in parts of 100 rather than in fractions of one. Substituting in the formula the total cases in each group and the mortality in each group, it is found that “P” equals 13.4, or that there are 13.4 chances in 100 that the difference in mortality in the two groups is due to chance or “random sampling” or limitation of the sample rather than to a true difference of statistical value. As for real statistical significance there should not be more than one chance in 100 that the difference is apparent rather than real ; it is obvious that in this comparison the difference in mortality is meaningless. MORTALITY
G-rq L---(l)
White, married, aged twenty-two, para i, gravida ii.
two months. Self-induced. generalized peritonitis.
Died in thirty-six
hours.
Autopsy:
Perforated
Gestation, uterus;
1032
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
Grmp B.-(l) White, married, aged seventeen, para i, gravida iii. Gestation, three months. Self-induced. Died in four days. Autopsy: Septicemia following abortion. (2) White, single, aged sixteen, para 0, gravida i. Gestation, two months. Denied induction. Died in twenty-eight hours. Autopsy: Poetabortal sepsis.
Chart 3 includes a list of those patients admitted with a temperature of 100”. It will be noted that the value of “P” is, in both instances, less than one; in other ~vorcIs, there is less than one chance in 100, in both the corrected and uncorrected mortality comparisons, that the difference is due to chance. In Group A, 3 patients required subsequent interference after intrauterine d&bridement on admission, on an average of six days later, while in Group B, 59 patients required operative intervention, averaging 5.4 days after admission. A. 6-
Awraq~ Averaqe
days days
5.5 8.9
(-1 (----I
Group A: Uterue emptwd on admwvxn Group i3: Treated conxrvatwly Casca A: 555
Cws
Mortahty: CorrPckd:
B: 233 Mortabty:
P : 0.014
5 -- 0.9% 3--0.54% 12 -5.
I %
Corrected:
7 - 3.0 7
Corrected:
0.37
The dramatic drop in temperature Pearce in this connection, occurred seems to coincide with the emptying ously or by operative means.
noted by Stewart, who quotes in many of these patients and of the uterus, either spontane-
MORTALITY
Grozlp L-1. White, single, aged thirty-one, para 0, gravida i. Gestation, three monPle Denied induction. Admitted as acute appendicitis on surgical division. Abdomen opened, closed and uterus emptied in operating room. Transferred to gynecologic service and died in six days of acute generalized peritonitis. (Omitted in corrected mortality.) 2.. White, married, aged twenty-three, para i, gravida ii. Gestation, 4 months. Denied induction. Uterus emptied on admission, packed. Again, same day, uterus invaded and patient repacked. Repeated a third time next day. Signed out eighth day; readmitted ten days later with temperature of 162’, and uterus invaded a fourth time. Death on twentieth day from peritonitis and septicemia. 3. White, married, aged thirty-one, para 0, gravida i. Gestation, three months. Entered in shock and did not respond. Died second day. Denied e induction. abortion; generalized peritonitis. Autopsy : septic
DRANE
:
TREATMENT
OF
INCOlRIl’LETE
10:x3
ABORTION
4. White, single, aged twenty-two, para 0, gravida i. Gestation, three months. Induction by physician. Died twenty-two hours after admission. Autopsy: gcneralized peritonitis. (Omitted in corrected mortality.) 5. White, married, aged thirty-six, para i, gravida iii. Gestation, two months. Denied induction. Died fourth day. Autopsy: septic abortion; generalized peritonitis. Grog B.-l. White, married, aged thirty-two, para vi, gravida vii. Gestation, three months. Denied induction. Treated principally for lo&r pneumonia. Die.d fourth day. Cause of death; lobar pneumonia. (Omitted in corrected mortality.) 0. Negro, married, aged thirty-three, para iv, gla\,ida v. Gestation t,hrce months. Denied induction. Operated first day as ectopic pregnancy. Died third (lay. Autopsy : septic abortion; generalized peritonitis. 3. White, single, aged thirty-one, para 0, gravida iv. Gestation, three months. Induction by physician. Died ninth day. Autopsy: septic abortion; generalized peritonitis. 4. White, single, aged nineteen, para 0, gravida i. Gestation, two and one-half months. Induction by midwife. Died sixth day. Autopsy: septic abortion; generalized peritonitis,
Correctpd.:5--3.5% P: 0.37
Corrected:
Subsequent InterFereweLB&e lwmq hospital)
2
27
0.93 Chart
.i.
5. Negro, widow, aged thirty-seven, para ii, gravida iii. Gestation, two and onehalf mont,hs. Denied induction. Treated principally for pneumonia. Died sixth day. Autopsy : lobar pneumonia. (Omitted in corrected mortabty.) two and one6. Negro, married, aged thirty-seven, para ix, gravida x. Gestation, half months. septic abortion, Denied induction. Died sixth day. Autopsy: septicemia. 7. Negro, Self-induced.
married, Died
S. White, married, Induced by physician. peritonitis. (Omitted
aged thirty-seven, para tenth day. Autopsy:
ii, gravida vii. septic abortion,
aged twenty-seven, para ?, gravida Died in three hours. Autopsy: in corrected mortality.)
Gestation, generalized
?bJ. Gestation, septic abortion;
9. White, single, aged twenty-two, para $, gravida ??. Gestation, Induced by physicia,n. Died in three and one-half hours. Autopsy: peritonitis following perforated uterus and sigmoid. (Omitted in tality.) 10. White, married, aged seventeen, Denied induction. Died third day. tonitis
para 0, gravida Autopsy: septic
two months. peritonitis.
i.
six weeks. generalized
two months. generalized corrected mor-
(Gestation, three months. abcrtion; generalized peri-
1034
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GT?iECOLOGV
11. Negro, married, aged thirty-six, para iii, gravida iv. Gestation, three and onehalf months. Self-induced. Died forty-fifth day. Autopsy: pelvic abscess ; thrombophlebitis, right leg. 12. white, married, aged thirty-four, para 9, gravida 1. Gestation, three months. Denied induction. Died in nineteen hours. Autopsy: septicemia; hemolytir: jaundice; thrombophlebitis left ovarian veins. (Omitted in corrected mortality.)
In an effort to correct a source of error that might be found in the fact that some of the patients admitted with high temperatures were considered too sick to subject to any operative procedure and would thus fall in the conservatively treated group, all cases in Chart 3 admitted with a temperature of lOlo, or higher, were listed separately and are summarized in Chart 4. In Group A every patient had a temperature of at least lOlo, with several as high as 106”, at the time the uterus was emptied with the ovum forceps. Not one complication that could in any way be blamed on the procedure occurred in this group. Again it will be noted that the value of “P” is less than one in both instances. The deaths are detailed under the discussion of Chart 3. In Group A, Nos. 4 and 5 ; in Group U. Nos. 1, 3, 4, 6! 7> 8. 9. and II. CONCLUSIONS
1. There were 92.3 per cent of the patients in this series married and 80.5 per cent had had an average of 2.6 full-term deliveries, apparently indicating the need of wider contraceptive education. 2. Results of treatment of all cases compare favorably as to morbidity and mortality with other recently reported series. 3. Best results were obtained in that group of cases where secundines were removed and drainage established by the method described.
Cotte, G., and Gat6, J.: Three Cases of Persistent Ano-Genital Pruritus Surgically, GynCcologie 34: 644, 1035.
Treated
The authors report three cases of stubborn anogenital pruritus which they They believe that in eldery women a vulrectomy should be treated surgically. performed, combined with removal of the clitoris and resection of the internal pudic nerves. However, in women who have an active sexual life and in those where the pruritus extends beyond the vulva and involves the anus, the buttocks ant1 the perineum and also in men, resection of the internal pudic nerves may not only not suffice but may result in disturbances in the sexual function. For these cases the authors recommend resection of the pelvic sympathetic plexus and also of the peri-iliac hypogastric sympathetics. If dnring the laparotomy any abnormalities arc found in the uterus or adnexa, these should be treated because there is no donbt, that certain cases of pruritus have their origin in reflex hypogastric plexalgia which is due to intrapelvic disturbances or in a plexitis secondary to a pelvic cellulitis. J. P. GREENHILL.
OF INCOMPLETE
RESULTS WALT=
H. DUNE, (Fawn
the
IN 1,971
CASES
M.D., BROOKLYN,
Eings
County
T
ABORTION N. Y.
Eospital)
HIS study is an effort to evaluate the results in the different forms of treatment of incomplete abortion as reflected in the records of a large general hospital. To this end all cases admitted to the Gynecological Division of the Kings County Hospital for the five yea,rs, 1930 through 1934, were reviewed, including all readmissions. There were 1,971 cases. No case in which the period of gestation exceeded four months is included because these patients were admitted to the obstetric service and treated as premature labor, the technic of which differs considerably from the accepted routiue on the gynecologic service. The diagnosis in all cases was made by the history, findings 011 pelvic examinatiou and by the gross demonstration of placent,al tissue ; in the great majority of cases this was confirmed 1):~ a detailed pa.thologic report. Treatment, where the procedure is possible, is essentially as follows : After a careful history, with emphasis on any invasion of the uterus, the patient is shaved, scrubbed, the vulva painted with tr. iodine, a,nd Using sterile gloves, a gentle bimandraped as for a major operation. ual examination is made to determine the size and position of the uterus, the dilatation of the cervix and presence or absence of adnexal pathology. If no adnexal pathology is present, tha cervix is steadied with a tenaculum and the secundines removed with a smooth ovum forceps. The patient is then put to bed in Fowler’s position, an ampule of pituitrin is given, followed by a course of ergot, usually one drachm every four hours for six doses. After demonstrations of this technic by the resident, the work is done almost entirely by the internes, who change services every two months. An elevation of temperature is not considered a contraindication, in the absence of a history of repeated outside interference or of associated pelvic pathology. Gentleness in making the pelvic examination and in using the ovum forceps is st,ressed. Packs are rawly used, an occasional indication being where bleeding is moderate and the cervix not dilated enough to admit, the ovum forceps. A eurette is never used as it is felt that, while a simple intrauterine debridement to remove infectious material and promote drainage is practically 10%
1030
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
without danger, even in inexperienced hands, the trauma and massage osf the uterine walls incident to the use omfa curette are responsible for the poor results and consequent widespread condemnation of active interference expressed by authorities in t,his country. Patients treated conservatively include those where the cervix does not admit an ovum forceps, where other gross pelvic pathology is present or where it is known that the uterus has previously been invaded. A history of interference is, of course, usually denied; nevertheless, all patients are questioned closely. Conservative treatment includes the use of oxytocics, clyses, infusions, and occasionally transfusions. The intravenous drip has been of benefit in septic cases. Curettage was necessary in most of the conservatively treated patients, either before leaving the hospital or at a later admission. SUMMARY
3
*
OF 1971
CASES
Awraqc
hospital
.5
‘
9
Recorded Complications Deaths LO - 1.0 X Generabred Pentomtls..13 Corrected - 0.65% Pelvic Abscess -- ..-- .-. 8 Pelvis Cellullt~s----~-------~.0 Para 1 plus-80.5 % Pelvic Thrombophlobttls--3 Pdra 0 -/&5 % PerforԦkd Uterus~------~--~ 1 Avwaqe parity-Z.6 Opened as Ectoplc-~---.----- 2 Opened a5 Fabroad----.------1 Prwous Abortions Shock ------.-.. --- --- ---.-47 One plus -40.8% Anemia----------------------53 NOW _ 59./X Readmmsions ~-----~--.- ----32 Subsequent Interftrence---53 Awraqo - 0.78 (Uterus emptlcd on adm.l Averaqo Gestation2.6 Mos. No previous Chart
days
5.8
10
Averaqc Aqo-28.6 fExtrum.s 14 -50) Aqe Groups: 11 to20 - m9z 2.1 ,, 30 -50.6% 31 ” 40 -31.3% 41 * 50 - 6.5% Married-22.3X,Smqle.~6% WLte-&?l%,Neqro-/S6% Treated operatively: 1652 or 83.8% preqnancios-13.2%
1.
In Chart 1, a summary of the entire series, it will be seen that the figures agree closely with those reported recently in other series. The temperature average presented here and in subsequent tables is based on rectal temperatures, so 99” was taken as a base line. The 53 patients requiring subsequent interference were those who, after removal of secundines by means of the ovum forceps on admission, were curetted before discharge for persistent bleeding. In addition to these data may be added: Of 891 cases where the Wassermann was recorded, 43, or 4.8 per cent, were positive. Of 279 who admitted induction, 210 were self-induced, 35 were induced by midwives, 22 by physicians, and 12 “had abortions performed. ” The majority of the rest offered falls, exertion, worry, fright, and a host Of t,he deaths, 17 out of 20 of other explanations for the abortion. had the exact cause determined by autopsy.
DRANE :
TREATMENT
OF INCOMPLETE
ABORTIOK
1031.
In Chart 2 are listed all patients who were admitted with a normal temperature, with a comparison in average temperature range, hospital days, mortality, and complications between those of the group where the uterus was emptied on admission by means of the ovum forceps and those treated conservatively. It will be noted that of the patients treated conservatively, 132 required operative intervention before discharge, which was done on an average of 4.9 days after admission. Of the radically treated group, 19 required a second operative intervention, averaging 5.3 days after admission. The value of “P” requires explanation. In the comparison of faetors in unequal groups of a limited quantity an obvious source of error is that the observed difference may be due to chance rather than to an actual difference. Through the courtesy of Dr. A. T. Rasmussen. of the lrniversity of Minnesota. a formula used by Dunn for the deterA- Averaqe B- Averaqo
days 4.7 L-1 days 7 4 (----..J
Group A: Utrrus e-mp&d on admisswn Group 8: Trrated Conscrvatwely Casea A: 886
Cases 0: 297
Mortahty: Corr
1 - - 0.N % - - 0.11 %
Mortality: L-- 0.672 Correctrd:Z--0.675:
P: 13.4
Chart
2.
mination of statistical significance of comparisons in limited samples was modified to apply to the problem at hand. The modification was in expressing the answer in parts of 100 rather than in fractions of one. Substituting in the formula the total cases in each group and the mortality in each group, it is found that “P” equals 13.4, or that there are 13.4 chances in 100 that the difference in mortality in the two groups is due to chance or “random sampling” or limitation of the sample rather than to a true difference of statistical value. As for real statistical significance there should not be more than one chance in 100 that the difference is apparent rather than real ; it is obvious that in this comparison the difference in mortality is meaningless. MORTALITY
G-rq L---(l)
White, married, aged twenty-two, para i, gravida ii.
two months. Self-induced. generalized peritonitis.
Died in thirty-six
hours.
Autopsy:
Perforated
Gestation, uterus;
1032
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
Grmp B.-(l) White, married, aged seventeen, para i, gravida iii. Gestation, three months. Self-induced. Died in four days. Autopsy: Septicemia following abortion. (2) White, single, aged sixteen, para 0, gravida i. Gestation, two months. Denied induction. Died in twenty-eight hours. Autopsy: Poetabortal sepsis.
Chart 3 includes a list of those patients admitted with a temperature of 100”. It will be noted that the value of “P” is, in both instances, less than one; in other ~vorcIs, there is less than one chance in 100, in both the corrected and uncorrected mortality comparisons, that the difference is due to chance. In Group A, 3 patients required subsequent interference after intrauterine d&bridement on admission, on an average of six days later, while in Group B, 59 patients required operative intervention, averaging 5.4 days after admission. A. 6-
Awraq~ Averaqe
days days
5.5 8.9
(-1 (----I
Group A: Uterue emptwd on admwvxn Group i3: Treated conxrvatwly Casca A: 555
Cws
Mortahty: CorrPckd:
B: 233 Mortabty:
P : 0.014
5 -- 0.9% 3--0.54% 12 -5.
I %
Corrected:
7 - 3.0 7
Corrected:
0.37
The dramatic drop in temperature Pearce in this connection, occurred seems to coincide with the emptying ously or by operative means.
noted by Stewart, who quotes in many of these patients and of the uterus, either spontane-
MORTALITY
Grozlp L-1. White, single, aged thirty-one, para 0, gravida i. Gestation, three monPle Denied induction. Admitted as acute appendicitis on surgical division. Abdomen opened, closed and uterus emptied in operating room. Transferred to gynecologic service and died in six days of acute generalized peritonitis. (Omitted in corrected mortality.) 2.. White, married, aged twenty-three, para i, gravida ii. Gestation, 4 months. Denied induction. Uterus emptied on admission, packed. Again, same day, uterus invaded and patient repacked. Repeated a third time next day. Signed out eighth day; readmitted ten days later with temperature of 162’, and uterus invaded a fourth time. Death on twentieth day from peritonitis and septicemia. 3. White, married, aged thirty-one, para 0, gravida i. Gestation, three months. Entered in shock and did not respond. Died second day. Denied e induction. abortion; generalized peritonitis. Autopsy : septic
DRANE
:
TREATMENT
OF
INCOlRIl’LETE
10:x3
ABORTION
4. White, single, aged twenty-two, para 0, gravida i. Gestation, three months. Induction by physician. Died twenty-two hours after admission. Autopsy: gcneralized peritonitis. (Omitted in corrected mortality.) 5. White, married, aged thirty-six, para i, gravida iii. Gestation, two months. Denied induction. Died fourth day. Autopsy: septic abortion; generalized peritonitis. Grog B.-l. White, married, aged thirty-two, para vi, gravida vii. Gestation, three months. Denied induction. Treated principally for lo&r pneumonia. Die.d fourth day. Cause of death; lobar pneumonia. (Omitted in corrected mortality.) 0. Negro, married, aged thirty-three, para iv, gla\,ida v. Gestation t,hrce months. Denied induction. Operated first day as ectopic pregnancy. Died third (lay. Autopsy : septic abortion; generalized peritonitis. 3. White, single, aged thirty-one, para 0, gravida iv. Gestation, three months. Induction by physician. Died ninth day. Autopsy: septic abortion; generalized peritonitis. 4. White, single, aged nineteen, para 0, gravida i. Gestation, two and one-half months. Induction by midwife. Died sixth day. Autopsy: septic abortion; generalized peritonitis,
Correctpd.:5--3.5% P: 0.37
Corrected:
Subsequent InterFereweLB&e lwmq hospital)
2
27
0.93 Chart
.i.
5. Negro, widow, aged thirty-seven, para ii, gravida iii. Gestation, two and onehalf mont,hs. Denied induction. Treated principally for pneumonia. Died sixth day. Autopsy : lobar pneumonia. (Omitted in corrected mortabty.) two and one6. Negro, married, aged thirty-seven, para ix, gravida x. Gestation, half months. septic abortion, Denied induction. Died sixth day. Autopsy: septicemia. 7. Negro, Self-induced.
married, Died
S. White, married, Induced by physician. peritonitis. (Omitted
aged thirty-seven, para tenth day. Autopsy:
ii, gravida vii. septic abortion,
aged twenty-seven, para ?, gravida Died in three hours. Autopsy: in corrected mortality.)
Gestation, generalized
?bJ. Gestation, septic abortion;
9. White, single, aged twenty-two, para $, gravida ??. Gestation, Induced by physicia,n. Died in three and one-half hours. Autopsy: peritonitis following perforated uterus and sigmoid. (Omitted in tality.) 10. White, married, aged seventeen, Denied induction. Died third day. tonitis
para 0, gravida Autopsy: septic
two months. peritonitis.
i.
six weeks. generalized
two months. generalized corrected mor-
(Gestation, three months. abcrtion; generalized peri-
1034
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GT?iECOLOGV
11. Negro, married, aged thirty-six, para iii, gravida iv. Gestation, three and onehalf months. Self-induced. Died forty-fifth day. Autopsy: pelvic abscess ; thrombophlebitis, right leg. 12. white, married, aged thirty-four, para 9, gravida 1. Gestation, three months. Denied induction. Died in nineteen hours. Autopsy: septicemia; hemolytir: jaundice; thrombophlebitis left ovarian veins. (Omitted in corrected mortality.)
In an effort to correct a source of error that might be found in the fact that some of the patients admitted with high temperatures were considered too sick to subject to any operative procedure and would thus fall in the conservatively treated group, all cases in Chart 3 admitted with a temperature of lOlo, or higher, were listed separately and are summarized in Chart 4. In Group A every patient had a temperature of at least lOlo, with several as high as 106”, at the time the uterus was emptied with the ovum forceps. Not one complication that could in any way be blamed on the procedure occurred in this group. Again it will be noted that the value of “P” is less than one in both instances. The deaths are detailed under the discussion of Chart 3. In Group A, Nos. 4 and 5 ; in Group U. Nos. 1, 3, 4, 6! 7> 8. 9. and II. CONCLUSIONS
1. There were 92.3 per cent of the patients in this series married and 80.5 per cent had had an average of 2.6 full-term deliveries, apparently indicating the need of wider contraceptive education. 2. Results of treatment of all cases compare favorably as to morbidity and mortality with other recently reported series. 3. Best results were obtained in that group of cases where secundines were removed and drainage established by the method described.
Cotte, G., and Gat6, J.: Three Cases of Persistent Ano-Genital Pruritus Surgically, GynCcologie 34: 644, 1035.
Treated
The authors report three cases of stubborn anogenital pruritus which they They believe that in eldery women a vulrectomy should be treated surgically. performed, combined with removal of the clitoris and resection of the internal pudic nerves. However, in women who have an active sexual life and in those where the pruritus extends beyond the vulva and involves the anus, the buttocks ant1 the perineum and also in men, resection of the internal pudic nerves may not only not suffice but may result in disturbances in the sexual function. For these cases the authors recommend resection of the pelvic sympathetic plexus and also of the peri-iliac hypogastric sympathetics. If dnring the laparotomy any abnormalities arc found in the uterus or adnexa, these should be treated because there is no donbt, that certain cases of pruritus have their origin in reflex hypogastric plexalgia which is due to intrapelvic disturbances or in a plexitis secondary to a pelvic cellulitis. J. P. GREENHILL.